The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.
|INTERFAITH MEDICAL CENTER||1545 ATLANTIC AVENUE BROOKLYN, NY 11213||Oct. 18, 2011|
|VIOLATION: STABILIZING TREATMENT||Tag No: A2407|
|**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on record review it was determined that the facility did not effectively ensure that all individuals with an emergency medical condition were effectively made aware of the need for further medical examination and treatment as required to stabilize the medical condition. This deficiency was noted in 4 of 5 applicable records reviewed.
Review of MR #22 noted that this patient, a [AGE] year-old female with no significant medical history (MDS) dated [DATE] at 1825 with a chief complaint of palpitation. The patient was triaged ESI 3 at 1829. She had a borderline ECG. The disposition was AMA and physician impression was palpitations, R/O CVA. On 9/26/2011 at 23:56, the MD noted the patient "refuses to wait for official report of the CT scan; risk, benefits and alternatives explained. The patient left AMA". The physician did not document the risks and benefits that were explained to the patient. A copy of the AMA form given to the patient that described the risks and benefits for signing out against medical advice was not in the medical record. The MD did not attempt to secure the patient's signature on the AMA form as indicated by the facility ' s policy and procedure.
MR #23 is a [AGE] year old female who (MDS) dated [DATE] at 1556 with complain of pain to hip and right leg. The patient was triaged at 1601 and assigned ESI 3. The patient was seen and evaluated by the ED physician at 1910; physician orders were documented at 1914 and 1918 for x- rays of the right hip, pelvis and Lumbar spine. The " Status Event History " showed the patient was back from radiology at 2000. Although the physician noted the patient left the ED against medical advice on 9/14/11 at 1235, there was no evidence that the risk of leaving the hospital without completing treatment was explained to the patient. The " Status Event History " notes that the patient departed on 9/14/11 at 1:39AM.
Similar findings were noted in MR #s 24 and 25; both patients left the ED against medical advice but there was no documentation that the facility attempted to secure a written refusal of treatment and document the risk.